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S A N J O A Q U I N Environmental Health Department <br />COUNTY <br />Greatness grows here. <br />SITE MITIGATION WELL (k BORING PERMIT APPLICATION <br />For Wells and Borings Used for Contaminant Investigations and Remediation <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />48 Hours Advance Notice Required For All Inspections <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. <br />This application is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3, and the San Joaquin County Well Standards, <br />Job Address 1444 Tillie Lewis Drive <br />Cross Street Naw Drive <br />Property Owner Via Del Oro Partners LLC <br />Address PO Box 60607 <br />C-57 Contractor ADVANCEDGEO, INC. <br />Address 837 SHAW ROAD <br />ConsultanUSub-ContractorADVANCEDGEO, INC. <br />Address 837 SHAW ROAD <br />City/State/Zip Stockton, CA 95206 Phone 209-466-1910 <br />APN 163-350-030-000 <br />City/State/Zip Palo <br />License# 1063765 <br />CA 94306 <br />City/StatelZip STOCKTON, CA 95215 <br />Phone 209-466-1910 <br />Phone 209-467-1006 <br />License# 1063765 Phone 209-467-1006 <br />City/State/Zip STOCKTON, CA 95215 <br />CONSTRUCTION WORK TO BE PERFORMED: *Note: Offsite Borings/Wells Require Access Agreements or Encroachment Permits <br />TYPE OF WELLIBORING <br />❑ MONITORING <br />El EXTRACTION (VaporM/ater) <br />® SOIL VAPOR PROBE <br />® SOIL BORING <br />❑ INJECTION (Air Soarae, Ozone/ <br />El OTHER <br />WELL/ SOIL BORING IDs SB1 - <br />NUMBER <br />El <br />2 El <br />n <br />INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />HOLLOW STEM BORING DEPTH 5 and 20 <br />HAMMERIDRIVEN DIA, OF BOREHOLE 1.5° and Y <br />MUD ROTARY CASING THICKNESS <br />_® PUSH POINT (GPI CPCONDUCTOR CASING ❑Yes NBoring <br />T) <br />_❑ HAND AUGER <br />El OTHER: <br />VP -1 -VP -2 <br />DESTRUCTION WORK TO BE PERFORMED: <br /># WELLS TO BE DESTROYED <br />WELL IDs <br />GROUT SPECIFICATIONS <br />TREMIE TYPE TO BE USED F1 AUGERS <br />❑HOSE 17 PIPE <br />❑BOLTED TRAFFIC BOX ❑STOVE PIPE <br />ElMULTIPLE CASINGS ❑MULTI-LEVEL WELL CASING DIA <br />TYPE OF CASING: ❑ STEEL El PVC El OTHER <br />❑ o <br />GROUT SEAL DEPTH 5 and 15 TREMIE TYPE TO BE USED: ❑AUGERS ❑HOSE ®PIPE <br />OUT SEAL PUMPED? El Yes ® No (Note: Maximum Freefall Depth is 30 Ft) <br />OUT SPECIFICATIONS Portland Cement 6 gallons per 94 lbs sack <br />Dia: Casing Dia: Casing Depth: <br />DESTRUCTION <br />Via Del Oro <br />FA Address <br />1444 Tillie Lewis <br />FA# <br />(}D �ZJI�7 <br />METHOD: <br />PR# <br />7LO �j.�3 <br />FA PE <br />2950 <br />(CHECK <br />WP Reviewed By <br />Michael Kith <br />DESTRUCTION <br />Via Del Oro <br />FA Address <br />1444 Tillie Lewis <br />FA# <br />(}D �ZJI�7 <br />METHOD: <br />PR# <br />7LO �j.�3 <br />FA PE <br />2950 <br />(CHECK <br />WP Reviewed By <br />Michael Kith <br />ALL <br />Work Plan Date <br />THAT <br />[Xi C-57 ElC-57Authorization for <br />Other to Sign Permit El <br />APPLY) <br />Encroachment Permit E] <br />Access Agreement [I Lead <br />Agency Approval IN MFR <br />COMMENTS/CoNDITIONS: All contents in soil <br />abandoned after completion of sampling. <br />vapor probes must be removed prior to abandonmenSoil vapor <br />probes must be <br />WP TYPE <br />PE <br />SC <br />FEE INFO <br />AMT REMITTED <br />CHECK# <br />RECV'D <br />❑ <br />OVER -BORE <br />DIAMETER of <br />inches to depth of feet <br />❑ <br />PRESSURE GROUT <br />To depth of <br />feet below surface <br />❑ <br />EXPLOSIVES <br />From <br />to feet below surface <br />MK <br />MUSHROOM CAP <br />1713 <br />feet below <br />surface or feet below surface if >3 feet <br />l7 <br />I hereby certify that I am authorized to complete this application and that the work will be done in accordance with <br />San Joaquin County Ordinance Codes and Standards, and all other applicable California laws. <br />/7 ♦ A/e U n <br />Signed #� ,�1/YI/`L/� Title/Company SENIOR GEOLOGIST/A.G.I. <br />Print Name Brian Millman Date 12/7/20 <br />DEPARTMENT USE ONLY <br />Application Accepted By: <br />Grout Inspection By/Dates: <br />Michael Kith <br />Destruction Inspection By/Dates: <br />Facility/Site Information <br />Date Issued: 12/16/20 <br />FA Name <br />Via Del Oro <br />FA Address <br />1444 Tillie Lewis <br />FA# <br />(}D �ZJI�7 <br />PR# <br />7LO �j.�3 <br />FA PE <br />2950 <br />WP Reviewed By <br />Michael Kith <br />Work Plan Date <br />12/7/20 <br />[Xi C-57 ElC-57Authorization for <br />Other to Sign Permit El <br />Workers Comp ❑ Workers Camp Waiver E] <br />Encroachment Permit E] <br />Access Agreement [I Lead <br />Agency Approval IN MFR <br />COMMENTS/CoNDITIONS: All contents in soil <br />abandoned after completion of sampling. <br />vapor probes must be removed prior to abandonmenSoil vapor <br />probes must be <br />WP TYPE <br />PE <br />SC <br />FEE INFO <br />AMT REMITTED <br />CHECK# <br />RECV'D <br />BY <br />DATE <br />WELL PERMIT# <br />INVOICE# <br />Permit <br />2905 <br />313 <br />$152 <br />x 3 <br />$456 <br />176637 <br />MK <br />12/16/20 <br />WP0041533 <br />1868 E. Hazelton Avenue � Stockton, California 95205 � T 209 468-3420 � F 209 464-0138 1 vvww.sjcehd.com <br />EHD 29-01 08-01-17 Site Mitigation Well Permit Application <br />